NEWS: Medication Abortion Through Telemedicine: Implications of a Ruling by the Iowa Supreme Court

Medication Abortion Through Telemedicine: Implications of a Ruling by the Iowa Supreme Court

By Y. Tony Yang and Katy B. Kozhimannil

From:
Obstetrics & Gynecology, Volume 127(2), February 2016, p 313–316

Excerpts:

On June 19, 2015, the Iowa Supreme Court issued a decision in the case of Planned Parenthood of the Heartland v. Iowa Board of Medicine. The Court unanimously
struck down a restriction that would have prevented physicians from administering a medication abortion (also known as “medical abortion”) remotely through video teleconferencing. In its ruling, the Iowa Supreme Court stated that the restriction would have
placed an undue burden on a woman’s right to access abortion services. The case was brought by Planned Parenthood of the Heartland, challenging the Iowa Board of Medicine’s 2013 decision requiring a physician’s physical
presence when a patient receives medication to induce an abortion. Before the Iowa Board of Medicine’s decision, patients in Iowa accessed many medical services, including medication abortion, through telemedicine. The Iowa Board of Medicine cited patient
safety concerns as the impetus for its policy change, but rigorous research shows that neither the number of abortions nor associated adverse outcomes increased in Iowa since the telemedicine option was first introduced in 2008. The
American College of Obstetricians and Gynecologists, which supports telemedicine access to medication abortion,4 raised
concerns that the Iowa Board of Medicine’s rule would pose a particular burden for rural residents seeking the procedure. In 2008, only 6.4% of obstetrician–gynecologists (ob-gyns) practiced in rural areas nationwide, and currently more than half of rural
women do not have access to reproductive health services anywhere in their counties. It is crucially important for clinicians—especially primary care clinicians, ob-gyns, and all health care providers of telemedicine
services—to understand the implications of this recent ruling, especially in rural settings. The Court’s decision has potential ramifications across the country for both women’s access to abortion and the field of telemedicine.

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The Iowa Supreme Court noted that telemedicine is being used to provide many types of health care services. But the Iowa Board of Medicine’s restriction singled
out medication abortion when it imposed a requirement that doctors be physically present to perform patient services. “It is difficult to avoid the conclusion that the board’s medical concerns about telemedicine are selectively limited to abortion,” the court
determined.

Today telemedicine abortion is available only in Iowa and Minnesota; 18 states have adopted bans on it. Other states neither expressly
allow nor ban telemedicine abortion. Nearly 21 million reproductive-age women live in the 18 states where the procedure is banned; these states also have substantial rural populations and few ob-gyns per capita, especially in rural counties. There are 200
telemedicine networks in the United States, with 3,500 service sites.10 Research
indicates that telemedicine ensures access to safe abortion services for rural women, but abortion politics are complex, and current laws reflect that abortion services are treated differently than other types of
clinical care provided through telemedicine. Increased use of telemedicine for abortion and other reproductive health services could help reduce the significant disparities in access that exist for women in rural communities compared with those in urban and
suburban areas.

Iowa is the first State Supreme Court to find a telemedicine abortion ban unconstitutional. Since the decision relied in part on federal constitutional law, it
can—and likely will—lead to challenges to telemedicine abortion bans in other states. If telemedicine abortions are indeed being unconstitutionally restricted, court decisions reversing these bans could improve access to abortion services for women in these
18 states. One of these states is Texas, where—in June 2015–the U.S. 5th Circuit Court of Appeals ruled that the state’s requirement that abortion clinics meet ambulatory surgical center standards did not impose an undue burden on a “large fraction” of Texas
women seeking abortions. Only a handful of Texas abortion clinics, all in major metropolitan areas, meet those standards. For women in rural Texas, telemedicine may present a safe, accessible alternative to accessing medication abortion services if that state’s
current ban on telemedicine abortion were lifted. Moreover, Texas women were reportedly already seeking abortion pills on the black market and crossing into Mexico for unsafe abortions owing to a lack of health care providers; therefore, access to safe medication
abortion is even more critical in places with limited access to clinic-based abortion services.

The ruling sets a precedent for how much authority state medical boards can exercise over the regulation of telemedicine. If the court had ruled for the Iowa
Board of Medicine, it could have opened the door for other state boards of medicine to limit the use of telemedicine for abortion or other politically controversial medical services (eg, emergency contraception), potentially circumventing the need for lengthy
state legislative processes to make policy change. The Iowa case is significant because, if the court had ruled that an appropriate patient–physician relationship could not be established or a proper diagnosis could not be made without the doctor’s physical
presence, it could have served as a springboard for increased state action in creating carve-outs and exceptions to telemedicine services, limiting the potential for populations with health care access issues to reap the full benefits of telemedicine, which
delivers safe medical services. Not unlike the recent Hobby Lobby

decision, this is a case that strikes deep into the political heart of the nation, but politics can obscure the core issues: access to safe medical care through telemedicine and what constitutes an appropriate patient–physician relationship and treatment options.
The Iowa decision emphasizes that available science, not political rhetoric, should drive America’s telemedicine policies.